Eye injuries and infections in austere conditions

Eye injuries are among the most anxiety-inducing field emergencies — the eye is small, accessible only through discomfort, and the stakes of permanent vision loss are clear to everyone involved. The good news is that the most common and most dangerous injuries (chemical splash, corneal abrasion, conjunctivitis) respond well to straightforward interventions available in any field kit. The hard limit is also clear: penetrating trauma and chemical burns require evacuation. Your job in the field is to correctly identify which category you're in and act accordingly.

Action block

Do this first: Irrigate the injured eye immediately with clean water or saline — start within 30 seconds of any chemical splash or visible foreign-body contamination; for trauma, assess for globe rupture before touching the eye (active time 2–5 minutes for assessment, 15–60 minutes for irrigation). Time required: Active: 15–60 min for irrigation; 2–5 min for assessment; recurrence: daily monitoring until resolved. Cost range: Inexpensive — a bulb syringe, saline ampules, antibiotic ophthalmic ointment, and cotton-tip applicators are the core kit. Affordable eye wash station for workshop/vehicle. Skill level: Beginner for irrigation and conjunctivitis management; intermediate for lid eversion and foreign-body assessment; do not attempt cornea-adherent object removal without training. Tools and supplies: Tools: bulb syringe or 20–60 mL irrigation syringe. Supplies: sterile saline or clean water, cotton-tip applicators, erythromycin ophthalmic ointment or tobramycin drops, rigid eye shield or improvised shield (paper cup bottom), litmus paper strips if available. Safety warnings: See Globe rupture and penetrating trauma below — any sign of globe rupture is a stop condition; do NOT irrigate, do NOT apply pressure; evacuate with rigid shield only.

Quick reference

Field	What to know
Outcome target	Vision preserved, pH normalized (7.0–7.4) for chemical burns, pain decreasing within 24–48 h, no corneal whitening or worsening discharge
First-line action	Irrigate immediately for chemical splash (15–30 min minimum); stabilize and assess for all other injuries before intervention
Escalate if	Penetrating injury suspected, chemical burn after initial irrigation, hyphema present, sudden vision loss, severe unrelenting pain, no improvement at 48–72 h, contact-lens wearer with any corneal injury
Stop if	Any sign of globe rupture (peaked/irregular pupil, soft globe on gentle palpation, prolapsed iris, 360° subconjunctival hemorrhage) — place rigid shield, do NOT irrigate or apply pressure, evacuate immediately

Educational use only

This page provides general educational information for emergency preparedness scenarios when professional medical care is unavailable. It is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of a qualified healthcare provider. Use this information at your own risk.

When to use this

Use this when:

A chemical or irritant has splashed into the eye — irrigation begins immediately regardless of other assessment
A foreign body is suspected in the eye — visible or strongly suspected from mechanism (grinding, sawing, drilling, wind-blown debris)
Symptoms suggest a corneal abrasion: intense foreign-body sensation, photophobia (light sensitivity), tearing, and redness — typically after an eye-rake, branch whip, or dust storm
Conjunctivitis (pink eye) has developed — discharge, redness, and matted lids requiring type differentiation before treatment
Blunt or penetrating trauma to the orbit — mechanism determines whether globe rupture is possible

Do not use this when:

Signs of globe rupture are present — this page does not guide treatment of an open globe; the only field action is rigid shield + evacuation (see escalation section below)
The patient reports sudden painless vision loss in one eye without trauma — this is a vascular emergency (retinal artery occlusion, central retinal vein occlusion, or acute angle-closure glaucoma) requiring immediate evacuation
Severe proptosis (bulging eyeball) is present — possible retrobulbar hematoma or orbital abscess; evacuate

Stop and escalate if:

Globe rupture signs appear at any point during assessment or irrigation
Vision acuity worsens during treatment
Any chemical burn — after the initial irrigation protocol, evacuate regardless of apparent severity
No improvement after 48–72 hours for any condition
Patient is a child with any eye injury — lower threshold for evacuation

Choosing a method

Match the approach to the mechanism and presentation. The table below covers the five injury categories this page addresses.

Category	Mechanism / Presentation	First-line field action	Proceed to	Evacuate?
Chemical splash	Known or suspected chemical in eye; burning, tearing, blepharospasm	Irrigate immediately 15–30 min (alkali: 60+ min)	pH check; secondary sweep	Yes — all chemical burns after initial irrigation
Mechanical foreign body	Grit, metal, wood — mobile or adherent sensation, unilateral injection	Irrigation first; lid eversion and conjunctival sweep	Antibiotics if corneal abrasion follows	If cornea-adherent object or metal-on-metal mechanism
Corneal abrasion	Intense foreign-body sensation, circumferential injection (redness), photophobia, tearing	Antibiotic ointment, oral analgesia	Daily monitoring; fluorescein check at 48 h if available	If no improvement at 48 h, white spot, contact-lens wearer
Conjunctivitis	Discharge, bilateral or unilateral, lid sticking; classify type before treating	Differentiate bacterial/viral/allergic; treat by type	5–7-day course antibiotics (bacterial) or supportive (viral/allergic)	If vision changes, severe pain, photophobia, no improvement at 3–5 days
Blunt / penetrating trauma	Impact mechanism; pain, vision change, periorbital hematoma	Assess for globe rupture first — do not irrigate until ruled out	Hyphema protocol or rigid shield if rupture found	Globe rupture or hyphema: yes, emergently

Steps

The sequence below guides you through initial assessment, then branches into injury-specific procedures by H3. Read the general assessment steps first regardless of injury type.

Initial assessment — before any intervention

Control the environment. Move the patient out of direct sunlight or wind that might cause further exposure. If chemical splash is ongoing, skip all other assessment steps and go directly to irrigation.
Assess vision in each eye separately. Ask the patient to cover one eye and count fingers held at arm's length, or read any nearby text. Note the difference between eyes. Decreased vision is the most critical finding — it escalates almost every injury category.
Inspect the orbit without touching the globe. Look for: periorbital hematoma (bruising), proptosis (globe displaced forward), lid lacerations, any visible wound entering the globe, foreign material on the surface of the eye.
Check pupil shape and reactivity. A peaked or irregular pupil (one side pulled toward a wound) is the field sign of globe rupture until proven otherwise. A teardrop-shaped pupil pointing toward a wound is a lacerated globe. If you see this: stop, place a rigid shield, evacuate.
Assess the anterior chamber. Look for a dark horizontal fluid level behind the cornea (hyphema — blood in the anterior chamber). This is visible as a red or dark arc at the lower part of the iris in good lighting.
Classify and proceed. Based on mechanism, symptoms, and the assessment findings above, proceed to the appropriate H3 section below.

Chemical splash and chemical burns

Chemical injury to the eye is the one scenario where you skip assessment and begin treatment immediately. Every second of exposure drives further penetration. The goal of irrigation is twofold: dilute and physically remove the chemical, and restore the ocular pH to physiologic range (7.0–7.4).

Before you start chemical irrigation: Materials: Clean water or sterile saline (at least 1 L / 34 oz per eye affected, more for alkali); bulb syringe or IV tubing; cotton-tip applicators; litmus paper strips if available . Conditions: Begin within 30 seconds of exposure. Do not stop to find saline if tap water or any clean water is available — begin with what you have. Alkali vs acid: Alkali burns (lye, lime, cement, ammonia) penetrate deeper than acids through liquefaction necrosis and require longer irrigation — 60 minutes or more. Acid burns cause coagulation necrosis that is largely self-limiting, but still require 15–30 minutes minimum .

Irrigation procedure:

Instruct the patient to blink rapidly to help distribute any debris-free chemical toward the drainage ducts for removal.
Position the patient supine or tilted slightly toward the affected eye so irrigant drains away from the nose and does not contaminate the other eye.
Hold the eyelids apart with your fingers or a speculum. The patient's blink reflex will be severe. Apply firm but gentle counter-pressure on the forehead and cheek to keep the lids open. Some providers use a bent paperclip (protected with gauze) as a makeshift speculum — this is field-expedient only; standard lid retractors or speculum preferred.
Direct a steady, gentle stream of water across the entire ocular surface. Hold the irrigation source 1–2 inches (2.5–5 cm) above the eye. Sweep from inner corner (nasal) to outer corner. For a bulb syringe: fill, hold 2 inches away, squeeze steadily. For IV tubing: run at medium flow, sweep back and forth.
Evert the upper lid after 3–5 minutes of irrigation. With the patient looking down, place a cotton-tip applicator horizontally across the upper lid (about 0.4 inch (1 cm) above the lid margin). Grasp the upper lashes gently, then fold the lid upward against the applicator to evert it. Irrigate the now-exposed upper fornix (the tissue fold behind the lid) directly.
Sweep the everted fornix with a moistened cotton-tip applicator. Particularly for lime, cement, or particulate chemicals — visible particles and chemical deposits lodge in the upper and lower fornix and cannot be removed by irrigation alone. Use a gentle rolling motion to clear the cul-de-sac.
Continue irrigating for the appropriate duration:
Acid burns: minimum 15–30 minutes
Alkali burns: minimum 30 minutes; extend to 60+ minutes because alkali penetration continues after the surface chemical is removed
Unknown chemical: treat as alkali; irrigate 30–60 minutes
Check pH if litmus strips are available. Wait 5 minutes after stopping irrigation before testing — retained chemical can transiently shift the reading. Target range: pH 7.0–7.4. If outside this range, resume irrigation for another 15–20 minutes and recheck. If no litmus: irrigate the full duration by time.
Watch for corneal whitening — a white, hazy, or opaque cornea after chemical exposure indicates a high-grade burn (Roper-Hall Grade III–IV). This does not change the irrigation protocol, but it is an escalation marker that mandates evacuation even if initial symptoms appear to improve.
After irrigation: patch both eyes loosely (to reduce painful conjugate eye movement), provide oral analgesia, and evacuate. Any chemical burn requires professional ophthalmic evaluation regardless of apparent symptom improvement — the extent of damage is not assessable in the field.

Alkali burns can continue penetrating

Alkali agents (ammonia, lye, calcium hydroxide from cement, drain cleaner) cause liquefaction necrosis — they continue penetrating corneal stroma even after the surface chemical is diluted. Standard acid burns self-limit from protein coagulation. When in doubt about the agent, irrigate as though it is alkali: 60 minutes minimum, check pH, restart irrigation if pH is not normalized.

Mechanical foreign body removal

A foreign body may be on the conjunctiva (the white of the eye and inner lid surface) or on the cornea (the clear central surface). These require different approaches and have different risk profiles.

Conjunctival foreign body (mobile, not fixed to cornea):

Irrigate first. Run clean water or saline across the eye from the inner to outer corner for 1–2 minutes. Many conjunctival foreign bodies will wash out.
Have the patient look in all directions while you observe the conjunctival surface with good light. Objects often lodge in the lower conjunctival fornix (the pocket below the eye).
Evert the upper lid to inspect the upper fornix. See the eyelid eversion technique described in the chemical splash section above. The upper fornix is the most common hiding place for eyelashes, dust particles, and small debris after the obvious areas are clear.
Remove conjunctival objects with a moistened cotton-tip applicator. Use a gentle rolling motion parallel to the surface. Do not drag the applicator — it risks further abrasion. Wipe the object toward the outer corner, away from the cornea.
Re-inspect after removal. Ask if the foreign-body sensation is gone. If it persists after thorough irrigation and sweep, the object may be on or in the cornea.

Corneal foreign body — superficial objects only:

Field / Austere Technique — last resort

Corneal foreign body removal is appropriate only for clearly superficial objects (sitting on top of the cornea without obvious adherence) when the patient has severe discomfort and the object is visible and discrete. A poorly executed attempt can abrade a larger area than the original object occupies, introduce infection, or, for metallic objects, push the particle deeper.

Reasonable to attempt when: - Object is visible as a distinct particle on the corneal surface - Object moves slightly or is clearly not embedded - No metal-on-metal mechanism (see below — intraocular foreign body risk) - The patient cannot tolerate the sensation and evacuation is more than 24 hours away

Do not attempt if: - Object appears adherent, surrounded by rust ring, or is clearly embedded - Mechanism was metal striking metal (grinding, machining) — assume intraocular penetration until proven otherwise - Object is at or near the visual axis (center of the cornea) - Any peaked or irregular pupil is present

Irrigate the cornea first. Moisten the surface and attempt to float the object off before any contact.
If a superficial object persists, use a moistened cotton-tip applicator. Touch the outer edge of the object (not the center) and use a gentle rolling motion to dislodge it. Do not apply downward pressure. One or two attempts only — if it does not move, stop.
Apply ophthalmic antibiotic ointment after any foreign body removal attempt, as even successful removal typically leaves a small epithelial defect (effectively a minor corneal abrasion). Continue antibiotic ointment per the corneal abrasion protocol below.

Metal-on-metal mechanism — special case:

Any mechanism involving metal striking metal at speed (grinding, chipping, machining, hammering metal) must be treated as a potential intraocular foreign body (IOFB) even if the patient sees and feels nothing. Metallic fragments ejected at high velocity are often too small to see and can penetrate the sclera with minimal pain. The Seidel test (a stream of aqueous humor leaking through a wound visible with fluorescein) requires clinical equipment and cannot be performed in the field. If the mechanism was metal-on-metal: place a rigid eye shield (no patch — it can press on the globe), give systemic antibiotics (ciprofloxacin 500 mg orally twice daily, or moxifloxacin 400 mg orally once daily, for adults as prophylaxis if available — IV vancomycin + ceftazidime is in-hospital standard but oral fluoroquinolone is the accepted austere/field substitute due to good vitreous penetration), and evacuate.

Corneal abrasion

Corneal abrasion is the most common traumatic eye injury in field settings. The corneal epithelium (the outermost layer of the cornea) is stripped away by a direct contact — a branch, fingernail, contact lens, dust particle, or foreign body removal. The result is intense pain, photophobia, tearing, and a gritty sensation that persists with every blink. The injury is uncomfortable, but most corneal abrasions heal within 24–72 hours if managed correctly.

Recognition:

Intense foreign-body sensation ("feels like sand under the lid") that does not resolve with blinking or irrigation
Circumferential injection — redness that forms a ring around the cornea, sparing the outer white of the eye (distinguish from conjunctivitis, which typically produces redness throughout the white)
Photophobia (light sensitivity) — often severe enough that the patient keeps the eye tightly closed
Profuse tearing from the reflex response
Typically unilateral and consistent with a mechanism

Fluorescein diagnosis (when available): A fluorescein strip or drop, examined under a UV penlight or Wood's lamp, will reveal an epithelial defect as a bright green area on the corneal surface. This is the field-accurate confirmation test but is not required to initiate treatment — mechanism and symptoms are sufficient.

Treatment procedure:

Remove any remaining foreign body using the procedure above if a particle is still present.
Apply topical antibiotic ointment. Erythromycin ophthalmic ointment (0.5%) applied to the lower conjunctival fornix four times per day is the first-line field choice for most corneal abrasions. Tobramycin drops (0.3%) are an alternative. Both prevent secondary bacterial infection of the epithelial defect.
Contact-lens wearer: If the patient wears contact lenses, the risk of Pseudomonas aeruginosa keratitis is significantly elevated. Erythromycin ointment does NOT provide anti-pseudomonal coverage. Use a fluoroquinolone drop (ciprofloxacin 0.3% or ofloxacin 0.3%) if available; if fluoroquinolone is not available, use tobramycin drops (which has some Pseudomonas activity) and evacuate sooner. Do not reinsert contact lenses until the abrasion is healed and clearance is given by a provider.
Do not patch the eye. Current evidence from the American Academy of Ophthalmology and Cochrane review does not support eye patching for most corneal abrasions. Patching does not reduce healing time and increases the risk of secondary bacterial keratitis by creating a warm, moist environment over a compromised surface. Exceptions are rare: large abrasions causing extreme pain may benefit from short-term pressure patching (no longer than 24–48 hours) under specific circumstances, but this is a clinical decision.
Manage pain.
Oral analgesia: ibuprofen 400–600 mg every 6 hours (with food) or acetaminophen 650–1,000 mg every 6 hours.
Cold compresses: a cool, clean cloth over the closed eye reduces the photophobia component.
Cycloplegic agents (homatropine 5% or cyclopentolate 1%) — if available — relieve the ciliary spasm that causes deep aching pain in larger abrasions. They are particularly helpful for abrasions involving the visual axis. These are prescription agents; include them in your medical kit if you carry other prescription-level ophthalmic supplies.
Instruct the patient to rest in dim light. Direct sunlight exacerbates photophobia and the blink reflex re-traumatizes the epithelium. Sunglasses or improvised eye shade significantly improve comfort.
Monitor daily. Check the eye each morning. Most corneal abrasions improve markedly within 24 hours and are fully healed within 72 hours. If the patient's pain is worsening rather than improving after 24 hours, or if a white spot appears on the cornea (corneal infiltrate or ulcer — typically a dense, opaque deposit in or under the epithelium), the injury has developed an infection and requires escalation.

Escalation criteria for corneal abrasion:

No improvement at 48 hours despite proper antibiotic treatment
Visible white spot, opacity, or infiltrate developing on the cornea
Contact-lens-related abrasion (higher risk; lower evacuation threshold)
Vision decrease at any point
Significant worsening of pain after the first 24 hours

Conjunctivitis differentiation and treatment

Conjunctivitis (inflammation of the conjunctiva) is the most common eye condition managed in the field over extended scenarios. The challenge is that the four primary types — bacterial, viral, allergic, and chemical/irritative — look superficially similar but require different treatment. Treating viral conjunctivitis with antibiotics is ineffective and contributes to resistance; failing to treat bacterial conjunctivitis with antibiotics prolongs the illness and increases spread risk.

Differentiation table:

Feature	Bacterial	Viral	Allergic	Chemical/Irritative
Discharge	Purulent, yellow-green, thick	Watery, thin, clear	Watery + stringy mucus	Watery, clears with removal of irritant
Both eyes?	Often unilateral initially	Often bilateral	Always bilateral	Corresponds to exposure
Lid sticking?	Yes — especially morning	Mild	Rare	No
Itching	Mild gritty sensation	Mild to moderate	Dominant symptom	No
Associated symptoms	None typical	URI, sore throat, fever	History of allergies, seasonal pattern	Known chemical or irritant exposure
Preauricular node	Absent	Often tender, palpable	Absent	Absent
Contagious?	Yes	Very — highest in viral	No	No

Treatment by type:

Bacterial conjunctivitis: Topical antibiotic therapy for 5–7 days. Erythromycin ophthalmic ointment applied to the inner lower lid surface, four times per day, is effective for most common bacterial pathogens (Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae). Tobramycin drops (1–2 drops every 4 hours while awake) are an acceptable alternative and preferred when vision clarity matters between doses (ointment blurs vision temporarily). Apply by gently pulling the lower lid down and placing the ointment or drops in the pocket — not on the eyeball itself.

Remove crusted discharge before each application using a clean, warm, moist cloth — one pass per wipe, discard or re-wet the cloth before the next pass to avoid smearing bacteria across the eye.
Wash hands before and after any eye contact.
Use separate towels and pillowcases for the affected person and discard or wash daily.

Viral conjunctivitis: There is no effective antiviral treatment for common viral conjunctivitis (most commonly adenovirus). Treatment is supportive: - Cool compresses several times per day reduce inflammation and discomfort. - Artificial tears (if available) lubricate and flush. - Avoid rubbing — it prolongs the inflammatory response. - Strict hand hygiene is the single most important infection-control measure; viral conjunctivitis is highly transmissible by fomite (touching shared surfaces). Duration: typically 1–2 weeks, improving around day 5–7.

Allergic conjunctivitis: - Remove or move away from the allergen source if identifiable. - Cool compresses provide significant relief. - Avoid eye rubbing — it degranulates mast cells and worsens symptoms. - Topical antihistamine drops (ketotifen, azelastine, olopatadine — if available over the counter) are effective. Oral antihistamines (diphenhydramine 25–50 mg, cetirizine 10 mg) have a modest eye effect but primarily reduce the systemic allergic response.

Hyperacute bacterial conjunctivitis — emergency: If conjunctivitis develops with copious, profuse purulent discharge that literally re-accumulates within an hour of wiping, suspect gonococcal (Neisseria gonorrhoeae) conjunctivitis. This is an ophthalmologic emergency that can perforate the cornea within 24–48 hours without systemic antibiotic treatment. In sexually-active adults: ceftriaxone 1 g intramuscularly single dose (if available) plus concurrent treatment for chlamydia (doxycycline 100 mg orally twice daily × 7 days, per CDC 2021 STI guidelines). Note: 1 g IM is the ophthalmic-specific ceftriaxone dose — higher than the 500 mg used for uncomplicated genital gonorrhea — because corneal perforation risk demands more aggressive coverage. One-time saline lavage of the infected eye is also recommended. In a newborn (ophthalmia neonatorum): this is a pediatric emergency requiring immediate evacuation. Topical antibiotics alone are not adequate for gonococcal infection.

Escalation criteria for conjunctivitis: - Any vision change or decrease in visual acuity - Significant photophobia (suggests corneal involvement — not typical for conjunctivitis alone) - Severe pain (not discomfort — severe pain suggests something more than conjunctivitis) - No improvement after 3–5 days of appropriate treatment - Contact-lens wearer with any conjunctivitis (higher risk of keratitis) - Suspected hyperacute (gonococcal) presentation

Globe rupture and penetrating trauma

This section covers the conditions that define the hard limit of field management. Globe rupture — an open wound of the eyeball itself — cannot be repaired without surgery. The field role is recognition, protection, and rapid evacuation.

Globe rupture recognition:

Look for any of these signs, all of which are definitive or near-definitive for globe rupture:

Peaked or irregular pupil — a pupil that is pulled toward one side or that forms a teardrop shape pointing toward a wound; caused by iris or vitreous prolapsing through the rupture
360° subconjunctival hemorrhage — blood completely surrounding the entire white of the eye in a ring (not just a patch); suggests equatorial rupture even when no entry wound is visible
Prolapsed iris or brown/uveal tissue at the wound site — dark-colored tissue visible on the white of the eye or in the wound
Hyphema (blood in the anterior chamber) with a visible wound — blood visible as a dark horizontal level in the lower iris; when combined with an entry mechanism, this confirms penetrating injury
Extremely soft globe on very gentle palpation — a normal eye has a firm, resilient feel; a ruptured globe feels soft or boggy. Do NOT palpate if any other sign is already present — this test is confirmatory only when other signs are absent and mechanism is ambiguous
Avulsion or obvious deformity of the globe

Do not irrigate or apply pressure to a suspected ruptured globe

Irrigation drives pressure into the eye, potentially expelling vitreous, iris, and retinal tissue through the wound. Pressure patches (and even gentle pressure from bandages) cause the same problem. Any suspected globe rupture needs a rigid shield only — not an eye patch.

Field management of globe rupture:

Stop any ongoing irrigation immediately if you were irrigating for another reason and now notice globe rupture signs.
Place a rigid eye shield over the orbit. The shield must rest on the orbital bones (the brow and cheekbone) — not on the globe itself. Commercial eye shields include Fox shields and plastic cup-style trauma shields. Improvised options:
The bottom half of a paper or foam cup, cut so the rim creates a ring that rests on the orbital rim. Tape the cup to the forehead and cheek with medical tape, leaving the cup elevated above the eye.
A folded cardboard piece shaped into a cone or bridge that spans the orbit without touching the globe.
Keep the patient calm and still. Anxiety and straining elevate intraocular pressure. Do not allow the patient to bend forward, lift, vomit without antiemetics, or perform any Valsalva maneuver. Position the patient with the head elevated 30–45 degrees if possible during transport.
Give oral antiemetics if vomiting is present (ondansetron 4 mg or promethazine 25 mg if available). Vomiting massively increases intraocular pressure and can worsen extrusion of globe contents.
Give systemic antibiotics for endophthalmitis prophylaxis. Austere/field options: ciprofloxacin 500 mg orally twice daily, or moxifloxacin 400 mg orally once daily (4th-generation fluoroquinolone — preferred when available for broader gram-positive coverage). Both achieve vitreous concentrations exceeding MIC₉₀ for common endophthalmitis pathogens. In-hospital standard is IV vancomycin + ceftazidime; do not delay evacuation to administer oral antibiotics if IV care is reachable within hours.
Do not give aspirin or NSAIDs — they increase bleeding risk. Acetaminophen 650–1,000 mg for pain.
Evacuate immediately. Globe rupture is a surgical emergency. The window for meaningful visual salvage narrows significantly after 12–24 hours. This is a P1 evacuation — it takes priority over all non-life-threatening conditions.

Hyphema (blood in the anterior chamber):

A hyphema is visible as a dark or red horizontal arc at the lower border of the iris — blood that has settled by gravity in the anterior chamber. Hyphemas range from microhyphema (visible only with magnification) to total hyphema (the entire iris is obscured by blood).

Most hyphemas follow blunt trauma and resolve spontaneously. Field management:

Apply a rigid eye shield (not a pressure patch).
Keep the patient's head elevated 30–45 degrees — this allows the blood to settle below the visual axis and reduces corneal staining risk.
Strict bed rest — no bending, straining, or exertion. Minimize eye movement.
Treat nausea promptly — any Valsalva maneuver risks re-bleeding.
No aspirin or NSAIDs (rebleeding risk). Acetaminophen for pain.
Evacuate — hyphema requires slit-lamp assessment and intraocular pressure monitoring for secondary glaucoma. Secondary hemorrhage (re-bleeding, typically on day 3–5) is the major complication and is not manageable in the field.

Subconjunctival hemorrhage (isolated):

Isolated subconjunctival hemorrhage — a bright-red patch on the white of the eye without any globe wound, hyphema, or vision change — is usually benign. Common causes: Valsalva (coughing, sneezing, straining), minor blunt contact, spontaneous in people on anticoagulants or aspirin. It reabsorbs over 1–2 weeks. No treatment required. Reassure the patient. Evacuate only if vision changes develop, pain is more than mild, or the mechanism was significant enough to suspect globe injury despite a normal pupil.

Orbital fracture signs:

Blunt trauma to the orbit can fracture the thin bones of the orbital floor or walls. Two specific findings indicate fracture requiring evacuation:

Emphysema (air palpable under the eyelid skin) — feels like bubble wrap beneath the lid; indicates orbital fracture communicating with a paranasal sinus. The patient should avoid blowing their nose, which forces air into the orbit.
Restricted upgaze with pain on attempted upward eye movement — suggests a blowout fracture of the orbital floor with entrapment of the inferior rectus muscle. This does not self-resolve and requires surgery if entrapment is confirmed.

Tools and substitutes

Ideal tool	Specs	Field-expedient substitute	Notes / limits
Eye wash station with saline	1–2 L sterile saline; pressurized	Clean water poured from any clean container	Volume matters more than sterility for chemical flush
Irrigation syringe (20–60 mL)	With flexible tip	Bulb syringe, squeeze bottle, IV bag with tubing	Gentle flow — do not jet directly at the cornea
Commercial eye shield (Fox shield)	Rigid plastic, orbital-rim fit	Paper cup bottom taped to orbital rim	Must not touch globe; tape to brow and cheekbone
Erythromycin ophthalmic 0.5% ointment	Prescription; ophthalmic grade only	Tobramycin drops (0.3%) if ointment unavailable	Non-ophthalmic antibiotics must NOT be placed in eye
Topical fluoroquinolone drops	Ciprofloxacin 0.3% or ofloxacin 0.3%; prescription	Tobramycin drops have partial Pseudomonas coverage	Contact-lens abrasions — fluoroquinolone strongly preferred
Litmus/pH strips	Narrow-range 6.0–8.0 preferred	None — irrigate by time only (15–60 min)	pH endpoint is ideal; time endpoint is acceptable
Cotton-tip applicators	Standard medical grade	Any clean cotton-tipped stick	Do not use dry — always moisten before ocular contact
Cycloplegic drops	Homatropine 5% or cyclopentolate 1%	None field-expedient safe	Oral analgesia + cold compresses as substitute for ciliary spasm relief

Failure modes

Undertreating alkali chemical burns

Operator-side failure: Stopping irrigation at 15 minutes because symptoms appear to be improving, or treating alkali burns on the same protocol as acid burns.

Outcome-side failure: Alkali penetration continues after the surface is flushed — the hydroxyl ions continue reacting with stromal protein even after dilution achieves neutral pH on the surface. Apparent symptom relief at 15 minutes does not mean penetration has stopped. Corneal whitening, limbal ischemia, and deep anterior segment damage can develop over the subsequent hours.

Recovery action: If you realize you under-irrigated an alkali exposure, resume irrigation immediately. There is no downside to additional irrigation time. If corneal whitening is already present, this is a Grade III–IV injury — escalate and evacuate emergently.

Attempting to remove a cornea-adherent foreign body

Operator-side failure: Using a cotton-tip applicator or sharp instrument to dislodge an object that does not move freely on the corneal surface.

Outcome-side failure: Driving the object deeper into the stroma, creating a large irregular abrasion, or, for metallic particles, scraping off the surface layer while leaving metal in the cornea (where it will cause a rust ring within 24–72 hours). Rust rings are not removable in the field and require professional debridement.

Recovery action: Stop after one or two gentle attempts. If the object does not move, do not escalate force. Apply antibiotic ointment, place a gentle patch or eye shield, and evacuate. The risk of leaving the object for 12–24 hours for professional removal is less than the risk of a traumatic corneal scar from a field attempt.

Misclassifying viral conjunctivitis as bacterial and prescribing antibiotics

Operator-side failure: Seeing a red eye with discharge and defaulting to antibiotic treatment without type differentiation. Viral conjunctivitis is more common in adults during upper respiratory illness seasons; bilateral watery discharge with preauricular lymph node tenderness strongly suggests viral etiology.

Outcome-side failure: Antibiotics have no effect on viral conjunctivitis. Using topical antibiotics contributes to resistance without clinical benefit. More importantly, the patient's condition may worsen and the provider will not recognize the failure because they "treated" it.

Recovery action: If the presentation is viral (watery, bilateral, URI symptoms, tender preauricular node), transition to supportive care. Reserve antibiotic treatment for purulent, unilateral presentations with lid sticking in the absence of URI symptoms. If uncertain and the patient is worsening despite 3 days of antibiotics, reconsider the diagnosis.

Missing globe rupture signs and irrigating a ruptured globe

Operator-side failure: Performing irrigation for what appears to be a chemical splash or foreign body, without first assessing pupil shape, anterior chamber, and overall globe integrity. Mechanism assessment is skipped under time pressure.

Outcome-side failure: Irrigation pressure drives aqueous humor, iris, vitreous, and in severe cases retinal tissue out through the rupture site, worsening the injury significantly and potentially eliminating any chance of vision salvage.

Recovery action: If you begin irrigation and then notice a peaked pupil, dark prolapsed tissue, or extreme softness of the globe: stop immediately. Tip the patient's head so any remaining irrigant drains away from the eye. Place a rigid shield, do not apply a patch, and evacuate urgently. Document the estimated volume of irrigant delivered.

Contact-lens abrasion treated as simple abrasion without Pseudomonas coverage

Operator-side failure: Applying erythromycin ointment to a contact-lens-related corneal abrasion without recognizing the need for anti-pseudomonal coverage.

Outcome-side failure: Pseudomonas aeruginosa keratitis can progress to corneal perforation within 24–48 hours in a compromised contact-lens wearer. Erythromycin has no significant Pseudomonas activity.

Recovery action: If erythromycin is already applied and the patient wears contacts, switch to tobramycin drops or ciprofloxacin drops immediately if available. If only erythromycin is accessible, double the application frequency and evacuate urgently.

When to evacuate — full criteria

Evacuate immediately for any of the following:

Globe rupture — any sign (peaked pupil, prolapsed tissue, soft globe, 360° subconjunctival hemorrhage)
Penetrating injury — any mechanism with possible ocular penetration, including metal-on-metal without visible findings
Hyphema — any blood in the anterior chamber
Chemical burn — all burns after initial field irrigation, regardless of apparent symptom improvement
Sudden vision loss — one or both eyes; any degree; with or without pain
Corneal whitening after chemical exposure (high-grade burn)
No improvement at 48–72 hours for corneal abrasion or conjunctivitis
White spot or opacity developing on the cornea at any time (corneal ulcer)
Contact-lens wearer with any corneal injury (lower threshold — evacuate by 24 hours if fluoroquinolone unavailable)
Orbital fracture signs — lid emphysema or restricted upgaze with pain
Hyperacute conjunctivitis — profuse purulent discharge re-accumulating within minutes
Any pediatric eye injury — lower threshold throughout; children's globes are more susceptible to injury complications and visual axis disruption during development
Proptosis — forward displacement of the globe (possible retrobulbar hematoma or abscess)

Eye-care kit — field checklist

Eye injuries can move fast — from a speck of grit to a corneal ulcer in 48 hours if a contact-lens abrasion is undertreated, or from a seemingly minor chemical splash to a destroyed anterior segment if alkali irrigation is stopped early. The page-level rule: when in doubt, irrigate more and evacuate sooner. For wound infection recognition following periorbital lacerations and facial injuries, the same escalation thresholds apply — expanding redness, fever, and streaking require the same urgency. For patients who have suffered significant facial or head trauma alongside an eye injury, coordinate the eye field management with the triage priorities from your overall casualty assessment — eye protection is secondary to airway and hemorrhage control. If you're managing eye care over days in an austere setting, wound care protocols for any associated periorbital lacerations apply with the same irrigation-and-monitor sequence described here.

Sources and next steps

Last reviewed: 2026-05-23

Source hierarchy:

American Academy of Ophthalmology — Chemical Injuries of the Cornea (Tier 1, AAO clinical guidance)
Wilderness Medical Society Clinical Practice Guidelines for Treatment of Eye Injuries and Illnesses in the Wilderness: 2024 Update (Tier 1, WMS peer-reviewed guideline)
AAO EyeWiki — Chemical (Alkali and Acid) Injury of the Conjunctiva and Cornea (Tier 1, AAO)
Merck Manual — How to Remove a Foreign Body From the Eye (Tier 2, Merck professional edition)
StatPearls — Ocular Burns (Tier 1, NCBI/NIH-hosted peer-reviewed reference)
StatPearls — Globe Rupture (Tier 1, NCBI/NIH-hosted)
CDC STI Treatment Guidelines, 2021 — Gonococcal Infections Among Adolescents and Adults (Tier 1, CDC — used for gonococcal conjunctivitis dosing)

Legal/regional caveats: This page addresses field management of eye injuries when professional ophthalmic care is unavailable or significantly delayed. All chemical burns, penetrating injuries, hyphemas, and globe ruptures require professional care as soon as evacuation is achievable — field management is temporizing only. Prescription ophthalmic medications (fluoroquinolone drops, cycloplegics) require a valid prescription in the United States; include these in a wilderness medicine kit obtained through a provider familiar with austere-environment medical planning.

Safety stakes: life-safety topic — verify against current local/professional guidance before acting.

Next 3 links:

→ Wound care — periorbital lacerations and facial wounds use the same irrigation and closure principles
→ Wound infection recognition and treatment — orbital cellulitis and periorbital infection escalation criteria
→ Triage in mass casualty events — eye injuries in multi-casualty scenarios — prioritization against airway and hemorrhage